HomeMy WebLinkAbout5640 (29)APPLICATION UIL IN
FOR APPLICANT TO FILL IN (Print or type only)
IL
BUILDING �y f
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BUILDING f v�j
ADDRESS �' �.. /
ADDRESS ® Gam'ax
CITY - ZIP
-
NO, OF BLDGS.
LOCALITY
SIZE OF LOT NOW ON LOT
NEAREST
CROSS ST.
ASSESSOR
TRACT BLOCK LOT NO
MAP BOOK PAGE
PARCEL
17 TEL. ✓j
$�'
DISTRICT GROUP TYPE FIRE
PROCESSED BY
OW NE -�6�G.,c.)/. /J
CONST ZO
�ry
ADDRESS
'
STATISTICAL CLASSIFICATION
SEWE MAP
CITY a.I ZIP
CLASS NO. _DWELL, UNITS
BK PG '..
ARCHITECT OR TEL.
ENGINEER NO.
USE ZONE MAP
'..
NO.
ADDRESS
SPECIAL
TEL,
CONDITIONS
CONTRACTOR NO
ROAD DEPARTMENT APPROVAL REQUIRED Y
NO
LIC.
ADDRESS NO,
BLDG, SETBACK FROM
LIC,
CITY
FRONT PROP. LINE OF
(STREET)
CLASS
-
HIGHWAY } YARD -_ TOTAL SE ACK FROM TYPE OF EXISTING
CONSTRUCTION LENDER
FRONT -PROP. PROP. LINE
HIGHWAY WIDTH
NAME AND BRANCH
+
ADDRESS CITY
SQ. FT.NO. OF NO, OF CHECK
BLDG, SETBACK FRO
D
(STREET)
SIZE STORIES FAMILIES ONE
SIDE PROP. LINE O
NEW ❑
HIGHWAY + ARD c TOTAL SETBACK FROM TYPE OF EXISTING`;
DESCRIPTION OF WORK
SIDE PROP. LINE
HIGHWAY WIDTH
' ADD ❑
+ -
L'
r, g
4
ALTER ❑
REPAIR❑
CORNER CUTOFF YES
NO
USE OF
EXISTING BLDG. _.��.-rG,.� OEMOL ❑
IN OPEN SPACE YES El
APPLICANT TEL
IN COASTAL ZONE YES ®
NO
(PRINT) NO.
CATEGORICAL EXEMPTION YES
® NO
BY (SIGNATURE) .
ENVIRONMENTAL
EXEMPTION DECLARATION SIGNED
(DATE)
IMPACT
VALUATION $j 6
IMPACT REPORT PROCESSED
(DATE)
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO CO LY
_
WITH ALL ORDINANCES AND LAWS REGULATING BUILDING C N-
STRUC TION. I CERTIFY THAT IN DOING THE RK ALIT RI ED
"SON I OLATIO OF THE
HEREBY I WILL NOT EMPLOY ANY'Cl
LABOR CODE OF THE STATE OF C �L.IF0 1 IN RE AT G TO
WORKMEN'S , - NSAT N INSURA C .
SIGNATUFa
FINAL
PERMI -
DATE
ADDR SS
p,C, PMT,Q
FEE P
T E L.
FEE
CITY NO.
PLAN CHECK VALIDATION
PERMIT VALIDATION / CK?
M.O. CASH
C'K. M.O. CASH
U y 1 3 7'7_
1 13 '17 2 3
8 1.6 0 #
76A638B CE4803A 5/73
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